Chitosan Nanoparticles for Intranasal Drug Delivery.

This manuscript explores the use of nanostructured chitosan for intranasal drug delivery, targeting improved therapeutic outcomes in neurodegenerative diseases, psychiatric care, pain management, vaccination, and diabetes treatment. Chitosan nanoparticles are shown to enhance brain delivery, improve bioavailability, and minimize systemic side effects by facilitating drug transport across the blood-brain barrier. Despite substantial advancements in targeted delivery and vaccine efficacy, challenges remain in scalability, regulatory approval, and transitioning from preclinical studies to clinical applications. The future of chitosan-based nanomedicines hinges on advancing clinical trials, fostering interdisciplinary collaboration, and innovating in nanoparticle design to overcome these hurdles and realize their therapeutic potential.

Quantum Dot Research in Breast Cancer: Challenges and Prospects.

The multifaceted role of quantum dots (QDs) in breast cancer research highlights significant advancements in diagnostics, targeted therapy, and drug delivery systems. This comprehensive review addresses the development of precise imaging techniques for early cancer detection and the use of QDs in enhancing the specificity of therapeutic delivery, particularly in challenging cases like triple-negative breast cancer (TNBC). The paper also discusses the critical understanding of QDs' interactions with cancer cells, offering insights into their potential for inducing cytotoxic effects and facilitating gene therapy. Limitations such as biocompatibility, toxicity concerns, and the transition from laboratory to clinical practice are critically analyzed. Future directions emphasize safer, non-toxic QD development, improved targeting mechanisms, and the integration of QDs into personalized medicine, aiming to overcome the current challenges and enhance breast cancer management.

Lipid Nanoparticles in Lung Cancer Therapy.

This manuscript explores the use of lipid nanoparticles (LNPs) in addressing the pivotal challenges of lung cancer treatment, including drug delivery inefficacy and multi-drug resistance. LNPs have significantly advanced targeted therapy by improving the precision and reducing the systemic toxicity of chemotherapeutics such as doxorubicin and paclitaxel. This manuscript details the design and benefits of various LNP systems, including solid lipid-polymer hybrids, which offer controlled release and enhanced drug encapsulation. Despite achievements in reducing tumor size and enhancing survival, challenges such as manufacturing complexity, biocompatibility, and variable clinical outcomes persist. Future directions are aimed at refining targeting capabilities, expanding combinatorial therapies, and integrating advanced manufacturing techniques to tailor treatments to individual patient profiles, thus promising to transform lung cancer therapy through interdisciplinary collaboration and regulatory innovation.

Epigenetics of the blood pressure reactivity to salt: Is the salt sensitive phenotype correctable?

Salt sensitivity defines a state characterized by a highly reactive blood pressure to changes in salt intake. The salt-sensitive phenotype is strongly associated with hypertension, visceral adiposity/metabolic syndrome, and ageing. Obesity accounts for around 70% of hypertension in young adults, and 30% to 50% of adult hypertensives carry the salt-sensitive phenotype. It is estimated that the salt-sensitive phenotype is responsible for high blood pressure in over 600 million adults. But is the salt-sensitive phenotype correctable? Interventional, controlled, clinical trials in obese adolescents and young obese adults, demonstrated that weight-reducing lifestyle modifications revert the salt-sensitive to the salt-resistant phenotype, and restored the faulty production of nitric oxide. Correction of the salt-sensitive phenotype lowers the blood pressure by reducing its reactivity to dietary salt. In a random sample of obese adults subjected to lifestyle modifications, those who were salt-resistant at baseline, were also normotensive and failed to further lower their blood pressure despite a 12% drop in body weight. The salt-resistant phenotype protects the metabolically healthy obese from hypertension, even if their salt consumption is comparable to that of salt-sensitive obese. In summary, at early stages, the elevated blood pressure of obesity, is determined by epigenetic changes leading to a state of salt-sensitivity.

Nanosystems in Cardiovascular Medicine: Advancements, Applications, and Future Perspectives.

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally. Despite significant advancements in the development of pharmacological therapies, the challenges of targeted drug delivery to the cardiovascular system persist. Innovative drug-delivery systems have been developed to address these challenges and improve therapeutic outcomes in CVDs. This comprehensive review examines various drug delivery strategies and their efficacy in addressing CVDs. Polymeric nanoparticles, liposomes, microparticles, and dendrimers are among the drug-delivery systems investigated in preclinical and clinical studies. Specific strategies for targeted drug delivery, such as magnetic nanoparticles and porous stent surfaces, are also discussed. This review highlights the potential of innovative drug-delivery systems as effective strategies for the treatment of CVDs.

Conductive polymers for cardiac tissue engineering and regeneration.

Cardiovascular diseases, such as myocardial infarction, are considered a significant global burden and the leading cause of death. Given the inability of damaged cardiac tissue to self-repair, cell-based tissue engineering and regeneration may be the only viable option for restoring normal heart function. To maintain the normal excitation-contraction coupling function of cardiac tissue, uniform electronic and ionic conductance properties are required. To transport cells to damaged cardiac tissues, several techniques, including the incorporation of cells into conductive polymers (CPs) and biomaterials, have been utilized. Due to the complexity of cardiac tissues, the success of tissue engineering for the damaged heart is highly dependent on several variables, such as the cell source, growth factors, and scaffolds. In this review, we sought to provide a comprehensive overview of the electro CPs and biomaterials used in the engineering and regeneration of heart tissue.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis.

PURPOSE: Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis. METHODS: The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods. RESULTS: Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis. CONCLUSIONS: The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Antiviral and anti-inflammatory drugs to combat COVID-19: Effects on cardiac ion channels and risk of ventricular arrhythmias.

Introduction: Drugs with no indication for the treatment of cardiovascular diseases (e.g., drugs employed to treat COVID-19) can increase the risk of arrhythmias. Of interest, a six-fold increase in the number of arrhythmic events was reported in patients with severe COVID-19. In this study, we reviewed (i) the pro-arrhythmic action of drugs given to patients with COVID-19 infection, and (ii) the effects of inflammatory cytokines on cardiac ion channels and possible generation of arrhythmias. Methods: We conducted a literature search on the drugs with purported or demonstrated efficacy against COVID-19 disease, emphasizing the mechanisms by which anti-COVID-19 drugs and inflammatory cytokines interfere with cardiac ion channels. Results: Antibiotics (azithromycin), antimalarials (hydroxychloroquine, chloroquine), antivirals (ritonavir/lopinavir, atazanavir), and some of the tyrosine kinase inhibitors (vandetanib) could induce long QT and increase risk for ventricular arrhythmias. The pro-arrhythmic action results from drug-induced inhibition of Kv11.1 (hERG) channels interfering with the repolarizing potassium IKr currents, leading to long QT and increased risk of triggered arrhythmias. At higher concentrations, these drugs may interfere with IKs, IK1, and/or Ito potassium currents, and even inhibit sodium (INa) and calcium (ICa) currents, inducing additional cardiac toxicity. Ibrutinib, an inhibitor of Bruton's TK, increased the incidence of atrial fibrillation and ventricular tachycardia associated with a short QT interval. Inflammatory cytokines IL-6 and TNF-α inhibit IKr and Ito repolarizing potassium currents. High levels of inflammatory cytokines could contribute to the arrhythmic events. For remdesivir, favipiravir, dexamethasone, tocilizumab, anakinra, baricitinib, and monoclonal antibodies (bamlanivimab, etesevimab, and casirivimab), no evidence supports significant effects on cardiac ion channels, changes in the QT interval, and increased risk for ventricular arrhythmias. Conclusion: This study supports the concept of hERG channel promiscuity. Different drug classes given to COVID-19 patients might delay repolarization, and increase the risk of ventricular arrhythmias. The presence of comorbid pro-arrhythmic disease states, and elevated levels of pro-arrhythmic cytokines, could increase the risk of ventricular arrhythmias. Discontinuation of nonessential drugs and correction of electrolyte abnormalities could prevent severe ventricular arrhythmias. Altogether, the most effective therapies against COVID-19 (remdesivir, dexamethasone, monoclonal antibodies) lack pro-arrhythmic activity.

A Comparison of SARS-COV-2 Neutralizing Antibody Therapies in High-Risk Patients with Mild to Moderate COVID-19 Disease at a Single Academic Hospital.

BACKGROUND: Bamlanivimab and casirivimab/imdevimab are recombinant neutralizing monoclonal antibodies that decrease viral load in patients with coronavirus disease 2019 (COVID-19) and can decrease hospitalizations. Few data exist comparing these two therapies. OBJECTIVE: Our aim was to compare the efficacy and safety of bamlanivimab and casirivimab/imdevimab in emergency department (ED) patients with COVID-19 who met criteria for monoclonal antibody therapy. METHODS: We performed a single-center, open-label, prospective study in adult ED patients with confirmed COVID-19 and high-risk features for hospitalization. Enrolled patients received bamlanivimab or casirivimab/imdevimab, depending on the day of the week that they arrived. We observed patients for post-infusion-related reactions and contacted them on days 5, 10, and 30. The primary outcome was the number of hospitalizations through day 30. In addition, we compared groups with regard to return visits to the ED, symptom improvement, antibody-induced adverse events, and deaths. RESULTS: Between December 17, 2020 and January 17, 2021, 321 patients completed the study. We found no statistically significant difference in the rate of subsequent hospitalization between groups (bamlanivimab: n = 18 of 201 [8.9%] and casirivimab/imdevimab: n = 13 of 120 [10.8%]; p = 0.57). In addition, we found no statistically significant differences between groups regarding return visits to the ED or symptom improvement. One patient had a possible adverse reaction to the treatment, and 1 patient died. Both of these events occurred in the bamlanivimab group. CONCLUSIONS: We found no statistically significant differences in rates of subsequent hospitalization or other outcomes for ED patients with COVID-19 when they received bamlanivimab as opposed to casirivimab/imdevimab. Adverse events were rare in both groups.

Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve?

INTRODUCTION: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). METHODS: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. RESULTS: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. CONCLUSIONS: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

Cell proliferation and anti-oxidant effects of oxytocin and oxytocin receptors: role of extracellular signal-regulating kinase in astrocyte-like cells.

OBJECTIVES: Oxytocin (OXT) participates in various physiological functions ranging from reproduction to social and non-social behaviors. Recent studies indicate that OXT affects cell growth and metabolism. Here we characterized the growth stimulating and antioxidant actions of OXT and of OXT receptors (OXTR) in a glial cell-line (U-87MG). METHODS: We developed an OXTR-knockdown cell-line (U-87MG KD) to establish the receptor specificity of OXT's actions, and the impact of lacking OXTR on growth and survival in glial cells. The role Extracellular-Signal Regulated Kinases (ERK1/2) on glial cell protection against consequences of oxidative stress, and cell proliferation was investigated. RESULTS: In U-87MG cells, OXT stimulated cell proliferation and increased ERK1/2 phosphorylation. The specific ERK1/2 inhibitor, PD098059, produced marked inhibition of cell proliferation, and antagonized the stimulating effect of OXT on ERK1/2 phosphorylation and on cell proliferation. Slower growth rates and lower levels of phosphorylated ERK1/2 were observed in OXTR-knockdown cells and in U-87MG cells treated with an OXTR antagonist (L-371,257). In addition to increasing cell proliferation, OXT significantly blunted the rise in reactive oxygen species induced by H2O2, and antagonized the reductions in cell viability induced by H2O2 and camptothecin. The cell protective and antioxidant actions of OXT in U-87MG cells were not observed in the OXTR-knockdown cells. CONCLUSION: OXT stimulates the growth of astrocyte-like cells acting on OXTR via ERK1/2 phosphorylation. The protection against apoptosis and the antioxidant capacity of OXT may contribute to the observed increase in cell proliferation. Oxytocin and OXTR appear to be fundamental for cell growth and viability of glial cells.

Can Prehospital Personnel Accurately Triage Patients for Large Vessel Occlusion Strokes?

BACKGROUND: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score was developed in the hospital setting to be used in the prehospital setting. It has been shown to have higher predictive value than comparable stroke scales, including the National Institutes of Health Stroke Scale, for identifying large vessel occlusion strokes. OBJECTIVE: We sought to determine whether prehospital FAST-ED scores are comparable with FAST-ED scores determined by emergency physicians. METHODS: Emergency Medical Services (EMS) personnel were trained to calculate a FAST-ED score for any patient suspected of having a stroke in the field. When the patient arrived at our ED, an emergency physician generated a FAST-ED score. RESULTS: One hundred and thirty-five patients were studied and large vessel occlusions were detected in 23.7%. There was no significant difference between median FAST-ED scores from EMS personnel (3; interquartile range [IQR] 1-5) and emergency physician (2; IQR 1-6). The difference between paired scores was not significantly different from 0 (median of paired differences was 0). In addition, prehospital FAST-ED scores were significantly and positively correlated with physician FAST-ED scores (r2 = 0.26). Comparable receiver operator curve area under the curve values were obtained for EMS FAST-ED (0.727; 95% confidence interval [CI] 0.638-0.816) and ED FAST-ED (0.769; 95% CI 0.669-0.868). CONCLUSIONS: The findings validate that prehospital FAST-ED scores are comparable in predictive value to FAST-ED scores calculated in the ED for prediction of large vessel occlusion strokes.

Does a Standardized Discharge Communication Tool Improve Resident Performance and Overall Patient Satisfaction?

INTRODUCTION: The discharge conversation is a critical component of the emergency department encounter. Studies suggest that emergency medicine (EM) residency education is deficient in formally training residents on the patient discharge conversation. Our goal was to assess the proficiency of EM residents in addressing essential elements of a comprehensive discharge conversation; identify which components of the discharge conversation are omitted; introduce "DC HOME," a standardized discharge mnemonic; and determine whether its implementation improved resident performance and patient satisfaction. METHODS: This was a prospective observational pre- and post-intervention study done by convenience sampling of 400 resident discharge encounters. Resident physicians were observed by attending physicians who completed an evaluation, answering "yes" or "no" as to whether residents addressed six components of a comprehensive discharge. The six components include the following: diagnosis; care rendered; health and lifestyle modifications; obstacles after discharge; medications; and expectations - or "DC HOME." Didactics introducing the mnemonic "DC HOME" was provided to resident physicians. Patient feedback and satisfaction were collected after each encounter, and we recorded differences between pre-intervention and post-intervention encounters. RESULTS: Resident physicians improved significantly in all six components of "DC HOME" from pre-and-post intervention: discharge diagnosis (P = 0.0036) and the remaining five components (P<0.0001). There was a statistically significant improvement in patients' perception for health and lifestyle modifications, obstacles after discharge, medications, expectations after discharge (P<0.0001), and discharge diagnosis (P = 0.0029). Patient satisfaction scores improved significantly (P = 0.005). Time spent with patients during discharge increased from 2 minutes and 42 seconds to 4 minutes and 4 seconds (P<0.0001). CONCLUSION: EM residents frequently omit key components of the discharge conversation. The implementation of the "DC HOME" discharge mnemonic improves resident discharge performance, patient perception, and overall patient satisfaction.

Emergency Medicine Resident-Driven Point of Care Ultrasound for Suspected Shoulder Dislocation.

OBJECTIVE: To determine the impact of implementing a musculoskeletal in-service educational intervention for emergency medicine (EM) residents on the use of point-of-care ultrasound (POCUS) to diagnose and manage shoulder dislocations in the emergency department (ED). METHODS: This study was conducted in the ED of an academic teaching hospital in Miami, Florida. It consisted of a short in-service educational intervention on how to perform and interpret POCUS, followed by an open, prospective convenience sample study in patients with clinical suspicion of shoulder dislocation. Twenty EM residents, with no prior shoulder scanning training, participated in the study. In all of the cases, the findings of the shoulder US were compared with radiographs, which were considered the reference standard. EM residents enrolled patients, and obtained and interpreted the shoulder US images. RESULTS: Seventy-eight patients were evaluated to rule out shoulder dislocation and/or fracture. Diagnosis of the dislocated shoulder was made in 55 of 78 patients, 53 of whom had anterior dislocations. Resident-driven POCUS had a sensitivity and specificity of 100% to diagnose and rule out, respectively, shoulder dislocations and relocations. There were no differences in the number of dislocations diagnosed and relocated by early and advanced EM residents. Results from a POCUS were available 22 ± 2.8 minutes sooner than x-ray for initial diagnosis and 27 ± 2.9 minutes (P < 0.0001) sooner than x-ray for assessment of reduction. CONCLUSIONS: EM resident physicians, with no previous training in shoulder US imaging, exposed to a brief in-service musculoskeletal education intervention, were able to diagnose shoulder dislocations via POCUS with high sensitivity and specificity. Shoulder US for dislocation should be a core component in EM training.

The Relationship Between Physician/Nurse Gender and Patients' Correct Identification of Health Care Professional Roles in the Emergency Department.

Background: A 2006 study of emergency medicine (EM) patients found male physicians were more often recognized as doctors that were female physicians. We sought to identify gender awareness of EM physicians and nurses by patients to see whether there has been a reduction in gender bias during the past 12 years. Materials and Methods: Before emergency department (ED) discharge or hospital admission, a convenience sample of 150 patients in an urban academic ED was anonymously surveyed to determine their awareness of the role of the health personnel involved in their care. Results: Our patients recognized male attending physicians as physicians 75.7% of the time and female attending physicians as physicians 58.1% of the time (p < 0.01). No differences were observed for resident physicians. Patients recognized male nurses as nurses 77.1% of the time, and female nurses as nurses 91.1% of the time (p < 0.01). Conclusions: These data indicate that patients continue to exhibit gender bias in the recognition of lead physicians and nurses.

Patients' Perceptions of the Role of Physicians in Questioning and Educating in Firearms Safety: Post-FOPA Repeal Era.

OBJECTIVES: In this study, we determined patients' attitudes toward discussing firearms and issues of firearms safety with emergency department physicians. We assessed whether patients feel discriminated against should physicians discuss firearms safety, and whether they believed that physician counseling may change how patients store firearms. METHODS: From June to October 2017, we conducted a cross-sectional institutional review board-approved survey of 200 consenting adult patients (convenience sample) not requiring critical care presenting to the emergency department of Mount Sinai Medical Center in Miami Beach, Florida. The survey consisted of 22 questions about perceptions of physicians inquiring about firearms, demographics, firearms statistics, and firearms knowledge. Results on firearms owners and nonowners were compared with the Fisher exact test. P < 0.05 was considered significant. RESULTS: Ninety percent of patients said they felt comfortable discussing firearms safety with a physician (firearms vs no firearms owner, 100% vs 87.5%, P = 0.028). Ninety percent (firearms 90.7% vs no firearms owners 89.9%, P = 1.0) of patients did not believe that physicians were discriminating against patients who are firearms owners when discussing firearms safety. Seventy-six percent (firearms 76.4% vs no firearms owners 77.3%, P = 0.367) of patients believed that physicians should be educating their patients about firearms safety, and 71% (n = 142) believed that education provided by physicians will change how people store their firearms (firearms 75% vs no firearms owners 70.2%, P = 0.67). CONCLUSIONS: Firearms safety is a difficult but important public health matter that requires significant intervention to help prevent future firearms incidents. This study supports physicians' efforts to help educate patients about the dangers of firearms, along with proper firearms storage techniques, showing that patients are largely open to this discussion. We propose that training of physicians in strategies for initiating clinical discourse and addressing firearms safety is needed.

How Much Time Do Residents Spend on Inpatient Clinical Computing?

OBJECTIVE: To evaluate the time that residents spend on clinical computing. METHODS: Our electronic health record system was used to record clinical computing time. Residents were unaware that we were tracking their time. Prior studies have reported computing times by watching the users. We evaluated residents in internal medicine, general surgery, and emergency medicine. The postgraduate year 1 (PGY1) and PGY3 residents were evaluated in July 2016 and January 2017. RESULTS: Emergency medicine residents spent approximately 3 hours/day and internal medicine and general surgery residents spent approximately 2 hours/day on clinical computing. For internal medicine and general surgery, there was a decrease in time spent on clinical computing from July to January and from PGY1 to PGY3. CONCLUSIONS: Residents in some specialties may decrease the time spent on clinical computing. There are many possible reasons for the changes. Our study serves as a computerized observation baseline for future assessments, interventions, and for developing improvements that increase the value of clinical computing.

Breaking the Barriers in Resident Education: A Quality Improvement Initiative.

INTRODUCTION: In 2013, the American College of Cardiology and American Heart Association updated the cholesterol guideline. Despite strong evidence supporting the recommendations, a discernible gap exists in the number of residents who practice them. Our study aimed to identify barriers hindering residents from guideline implementation. METHODS: Twenty eight residents were administered a preintervention and postintervention questionnaire to identify barriers in guideline application. The questionnaire was categorized into three barriers: knowledge, attitude, and behavior. A multifaceted educational intervention consisting of directed teaching sessions and supervised patient encounters was conducted. RESULTS: Our analysis showed that our residents lacked awareness, familiarity, and self-efficacy in using the cholesterol guideline. The intervention led to significant improvements in awareness (79% vs. 43%, p = .0129), familiarity (61% vs. 29%, p = .0306), and self-efficacy (65% vs. 16%, p = .0018) and achieved a 31% increase in knowledge (p = .0001), 38% in attitude (p = .0001), and 20% in behavior (p = .019). The overall improvement in scores averaged 30% (p = .0001). CONCLUSION: Our quality improvement initiative successfully improved our resident's comprehension and applicability of the 2013 ACC/AHA cholesterol guideline. We recommend a multifaceted educational approach tailored toward addressing specific barriers to improve the practice of evidence-based medicine.

Outcomes of Patients Who Have Do Not Resuscitate Status prior to Being Admitted to an Intensive Care Unit.

Admission of patients who have do not resuscitate (DNR) status to an intensive care unit (ICU) is potentially a misallocation of limited resources to patients who may neither need nor want intensive care. Yet, patients who have DNR status are often admitted to the ICU. This is a retrospective review of patients who had a valid DNR status at the time that they were admitted to an ICU in a single hospital over an eighteen-month period. Thirty-five patients met the criteria for inclusion in the study. The primary reasons for admission to the ICU were respiratory distress (54.2%) and sepsis (45.7%). Sixteen (45.7%) of the patients died, compared to a 5.4% mortality rate for all patients admitted to our ICU during this period (p < 0.001). APACHE II score was a significant predictor of mortality (18.5 ± 1.3 alive and 23.4 ± 1.4 dead; p = 0.038). Of the 19 patients discharged alive, 9 were discharged home, 5 to hospice, and 4 to a post-acute care facility. Conclusions. Patients who have DNR status and are admitted to the ICU have a higher mortality than other ICU patients. Those who survive have a high likelihood of being discharged to hospice or a post-acute care facility. The value of intensive intervention for these patients is not supported by these results. Only a minority of patients were seen by palliative care and chaplain teams, services which the literature supports as valuable for DNR patients. Our study supports the need for less expensive and less intensive but more appropriate resources for patients and families who have chosen DNR status.